Easy read Consent Easy read Consent Please enable JavaScript in your browser to complete this form. Easy Read Consent Form Easy Read Consent Form Territory Disability Services Please answer these questions Have you seen the “What you need to know: Easy Read” about getting help from <company name>? YES NO Has a <company name> worker told you about your rights and responsibilities at <company name> in a way you can understand? YES NO Has a <company name> worker answered any questions you might have about how we use your private information? YES NO Do you know how to make a complaint about <company name> if you are unhappy? YES NO Is it okay if we send you newsletters or ask you if you would like to go to events? YES NO Your information – it’s private When you become an <company name> client, we will need some information from you. We usually need to know: Your name and your contact details Your family, carer or support person’s contact details Some information about your health and wellbeing This information will help us provide you with a good service. We will keep all your information in a personal file in a private and safe area. Are you okay to give us this information so that we can help you? YES NO Please write down the people or services we can also share your personal information with: Name of person / service Help they provide Type of information to share Consent & signature Your name Your signature (type name) Date <company name> worker to complete Consent by Client Verbal consent Guardian or other person Witness signature Date Witness name Witness role Questions & answers about giving your personal information What if I have questions about the personal information you have about me? Just ask! We will tell you why we need your information, what we do with your information, and how we keep it safe. Is information about me given to anyone else? It is usually only given when you say it’s okay. We may need to give information to other services to help you with things like housing or jobs. We check this form and ask you before sharing. You can change your choices at any time. Why do I have to sign more than one consent form for some services? Sometimes services have funding that need a separate form. These may not ask about receiving <company name> news or events. Submit Reset Submit
